- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $6.03
| Facility | | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $6.03 / $45.71
| Professional | | $3.02 | $6.03 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.33 / $10.47 / $10.47
| Professional | | $9.33 | $10.47 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $12.02
| Facility | | $6.03 | $6.03 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $12.30 / $18.20
| Professional | | $6.03 | $12.30 | $18.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.76 / $11.75 / $79.43
| Facility | | $6.76 | $11.75 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $5.37 / $10.96
| Professional | | $3.55 | $5.37 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $28.84
| Professional | | $11.75 | $11.75 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $12.02 / $12.02
| Facility | | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $26.92 / $28.84
| Professional | | $14.79 | $26.92 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.72 / $5.75 / $10.96
| Facility | | $3.72 | $5.75 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.89 / $5.37 / $8.32
| Professional | | $3.89 | $5.37 | $8.32 |